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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S• ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 11566 St Rt Hwy 26 omiMPStockton 95215 <br /> m <br /> D <br /> CROSSSTREET Re.eChPr—RP APN 1 0 31 8 O O 1 PARCEL SIZE iqq LAND USE APPLICATION# In <br /> p <br /> In <br /> OWNERNAME John A Davis Farms LLC PHONE y <br /> OWNE2ADDRESS _6481 E. Morada Ln CITY/STATF/LPStQckton.CA 95212 <br /> CONTRACTOR Purviance Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 CITY/SrATE2iPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 _C-61 :]D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY: .;OWNER L CONTRACTOR h SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)[1 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE L Domestic/Private ❑In igation/Agricultural ❑Industrial L Water Quality Monitoring ^Soil SamplinglCharacterization <br /> ❑Public Water System <br /> If Different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well C Replacement Well ❑Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells C Soil Borin s #of bodng3 #of borings <br /> 9O �Geotechnical s D <br /> Out-0f-Service Well Out-Of-Service Well Renewal C Cross-Connection Repair O <br /> New Pump Pump Replacement. jif Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION Sq Q <br /> Drilling Method .:Mud Rotary Air Rotary J Auger :.:Cable Tool Push Point E Other N J J 2^O2 O <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom C Gravel Pack/Gravel Size__fit p �� r oUN <br /> Conductor Casing in diameter / Conductor Casing Depth It `` ly Epq RTTQ T y <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched -Steel ❑Plastic D Stainless Steel :]Other <br /> Grout Seal Depth E ft ::Neat Cement(941b bag/5-10 gat water) E Sand Cement sack mix/7 gal water Nr <br /> Bentonite(20%solids) iJ Other <br /> Grout Placement Method -Pumped -Free Fall G Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I Pump Contractor O Other <br /> i.l Concrete Pedestal7_Dimenslons:Width ft Length It Thick in G Christy Box �Stove Pipe <br /> PUMP 'u Submersible Turbine r HP O Pump Set O It Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 AAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMLINI d.R HOUR ADVANCE NOTiCE'R3"•;;URF0 FCR ^•T <br /> SIGNED TITLE <br /> DATE <br /> DEPARTMENT USE ONLY <br /> cs, <br /> Application Accepted By �r�l✓L--- � <br /> Date ti J.xC. Area � / ! Employee ID# <br /> Grout Inspection By Date ] SPECIAL Well Permit <br /> Pump Inspection By �v`c nc;,L, 0-.f Date ly 1134 Z 6: -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info sh Remitted Date rvlce Re u t# Invoice# Well ID# <br /> F-HD43-06 &1v2019 <br /> I4570/ <br /> 57 / ^ „� WELL/PUMP PERMIT <br />